University of Sao Paulo

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Breakfast patterns and weight status among adolescents – a study on the Brazilian
National Dietary Survey 2008-2009
Bruna Kulik Hassan1*, Diana Barbosa Cunha2, Roberta de Oliveira Santos3, Valéria
Troncoso Baltar1
1
Department of Epidemiology and Biostatistics, Institute of Collective Health, Fluminense
Federal University, Rio de Janeiro, Brazil.
2
Department of Epidemiology, Institute of Social Medicine, State University of Rio de
Janeiro, Rio de Janeiro, Brazil.
3
Department of Nutrition, School of Public Health, University of Sao Paulo
*Corresponding author: Bruna Kulik Hassan. Address: Travessa Marquês de Paraná,

303/3º andar. Centro. CEP: 24030210 - Niterói, RJ - Brasil. Email:
bruna_hassan@id.uff.br. Phone: +55 21 99070-4129.
Running title: Breakfast patterns and weight status
This peer-reviewed article has been accepted for publication but not yet copyedited or
typeset, and so may be subject to change during the production process. The article is
considered published and may be cited using its DOI
10.1017/S0007114521002403
The British Journal of Nutrition is published by Cambridge University Press on behalf of
The Nutrition Society
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Accepted manuscript
Abstract
Examine the composition of breakfast concerning weight status is essential for evaluating
adolescent health and understanding this gap. This study aimed to identify breakfast
patterns and investigate the relationship with weight status among Brazilian adolescents.
We used a subsample of 7,425 adolescents aged 10-19 years from the 2008-2009 Brazilian
Household Budget Survey. Breakfast eaters were those with intake of at least 50 kcal
(209.2kJ) between 5 and 10 a.m. Breakfast dietary patterns were derived by principal
component factor analysis with varimax rotation. We performed logistic regression
analyses between breakfast patterns and weight status, considering the complexity of the
survey sample design. Three breakfast patterns were identified explaining 44.8% of data
variability: (1) the Cereal, protein, fruit beverages and Northern/Northeastern pattern,
characterized by high consumption of cookies, meats, dairy products, preparations with
corn, eggs, fruit juices/fruit drinks/soy-based drinks, tubers/roots/potatoes, and cereals, and
negative adherence to cold cut meat and savory snacks/crackers; (2) the Protein-based
pattern, characterized by positive loadings for cold cut meat, milk and cheese, and negative
for cookies, fruit juices/fruit drinks/soy-based drinks, tubers/roots/potatoes, and cereals;
and (3) the Mixed pattern, with positive loadings for cakes, coffee/tea, bread, fruit
juices/fruit drinks/soy-based drinks, chocolate/desserts, and savory snacks/crackers. No
association was found between skipping and weight status. Overweight adolescents had
lower adherence to the Cereal, protein, fruit beverages and Northern/Northeastern pattern
pattern (OR=0.67; 95% CI 0.47; 0.96). This is the first study to address dietary patterns at
the meal level with adolescent population-based data, which requires further investigation.
Keywords: adolescent, body mass index, breakfast, dietary pattern, population-based.

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Introduction
Childhood obesity is a global challenge due to its increasing global prevalence that
will overwhelm health systems and economies in Brazil and other countries (1,2). Without an
effective public policy to manage the problem, Brazil is expected to become the fifth
country in the number of obese aged 5-19 years old, representing 7.7 million children(3).
Only behind Mexico, Brazil assumes the second position of the highest Gross Domestic
Product (GDP) loss due to obesity among Organization for Economic Cooperation and
Development (OECD) countries(4). With a higher risk to persist to adulthood(5,6), obesity
negatively affects school development. It is related to weight-related stigma, which can
impair the quality of life(7,8). Childhood obesity has also been associated with higher blood
pressure, lower levels of HDL cholesterol(9) and higher fasting glucose(10).
Identifying dietary patterns is relevant due to its higher capacity to predict overall disease
risk than assessment based on individual food or nutrient intake(11,12). People consume
meals that consist of synergic and complex combinations of several foods and nutrients (12).
The Brazilian Population Dietary Guidelines state that diet should consider meals and
eating patterns more than nutrients and foods and provide guidance on food combinations
for breakfast and other main meals (lunch and dinner)(13). The Brazilian Dietary Guide is
an international reference due to its scope and accessibility in the approach of healthy
eating and sustainability, besides the clear recommendations of the Brazilian diet to be
plant-based and based on fresh and processed foods, thus avoiding the ultraprocessed
products(14,15).
Research on the role of breakfast skipping and breakfast composition on obesity

remain inconclusive(16) despite the importance of breakfast’s composition for healthy
eating(17-19). This is partially due to unstandardized methodological breakfast definitions
between studies and variations considering the local context(20,21). A posteriori
identification of breakfast patterns according to the correlations between food items could
contribute to understand dietary patterns at the meal level further. Despite most commonly
consumed food groups by Brazilian adolescents at breakfast are coffee and tea, breads,
butter/margarine,milk, cakes and cookies, packaged snacks, corn-based dishes, cheese,
processed meats, and fruit juice, with saturated fatty acids, sodium and free sugar
exceeding the recommended maximum limits of daily energy intake, (22) understanding how
the composition of the breakfast relates to obesity is a further gap to be evaluated.
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Few studies have focused on dietary patterns at the meal level(23,24). In Brazil, while
one in every four adolescents is overweight (25), the relationship between dietary breakfast
patterns and weight status in adolescents is a gap that must be evaluated. Thus, this study
aims to address breakfast patterns and investigate the relationship with weight status
among Brazilian adolescents by using population-based data.
Methods
Study population and variables’ measurement
Brazilian representative study data on the cross-sectional National Dietary Survey

(NDS) with a 25% representative subsample (n=34,003 individuals) of 10-year-old or
above household members from the Brazilian Household Budget Survey (HBS) 2008-2009
(n=55,970), coordinated by the Brazilian Institute of Geography and Statistics (IBGE) with
a representative sample of Brazilian households (26). A two-stage cluster sampling was
conducted for the HBS. Primary sampling units were census tracts from 550 sampling
strata. This stage considered geographical and socioeconomic homogeneity. Private
permanent households composed the secondary sampling units. Adults and elderly,
pregnant women, and breastfeeding mothers were excluded from the NDS study, resulting
in a subsample of 7,425 adolescents aged 10-19 years.
Data on two non-consecutive days’ food records were collected from NDS
participants. Participants were asked to record all foods and beverages consumed each day
(food items, amount consumed, time, and place). Usual energy intake for each food was
obtained from NDS food composition and food portion tables(27,28). More information on
training and validation of the food records can be found elsewhere(26).
Despite giving useful information on dietary intake, food records capture short term
intake and, as consequence, fail to estimate day-to-day variation. To overcome this
limitation, we obtained usual food, daily and breakfast energy intakes with the National
Cancer Institute method (NCI), that consider within person variability, zero intakes, and
inclusion of covariates to improve intake prediction (age, sex and country region).
First, food records were analyzed to evaluate which food item was consumed in
each hour of the day. As definition of eating occasion was not available in the food records
every hour with any food consumption was defined as an eating occasion. We then
calculated the energy intake for each eating occasion. Second, each food record between
5:00 a.m. and 10:00 a.m. was examined. Third, we classified as breakfast eaters were those
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who consumed at least 50 calories (209.2 kilojoules) in the breakfast usual energy intake
between 5 a.m. and 10 a.m. When more than one eating occasion occurred in the delimited
interval the most caloric meal was chosen as breakfast. Breakfast-skippers were the
adolescents with usual energy intake below 50 calories and zero energy consumption in
both food records in the delimited period. The criteria to define the breakfast by time clock
and energy intake was based on the previous literature and other studies applied the same
breakfast frequency criteria(23,29).
Body Mass Index (BMI) [weight/(height)2] was calculated on measured weight
[with a portable electronic scale with 150 kilograms (kg) capacity and graduations of 100
grams (g)] and height [with a portable stadiometer with a retractable treadmill measuring
up to 200 centimeters (cm) and 0.1 cm precision]. Imputation procedures were applied for
erroneous or missing responses at the critical review stage. Detailed information is
available and published elsewhere(30).
Weight status was evaluated by using BMI-for-age z-score cutoff points based on
the reference population aged 5-19 years, proposed by World Health Organization
(WHO)(31). BMI-for-age z-scores were estimated with WHO-Anthro Plus, version 3.2.2(32).
WHO classifies (1) thinness when BMI-for-age < - 2 z-scores; (2) adequate BMI-for-age >
- 2 and <+1 z-scores; (3) overweight when BMI-for-age >+1 and <+2 z-scores; and (4)
obesity when BMI-for-age > +2 z-scores.
Anthro-Plus WHO child's age limits the BMI-for-age analysis to 228 completed
months. Since there were 570 (7.68%) non-classified data for participants older than 228
months, their weight status was based on adult BMI classification. Criteria for 19-year-old
individuals used in this study were consistent with the definitions set forth by the WHO
where: BMI < 18.5 kg/m2 is classified as underweight; BMI 18.5-24.9 kg/m2 as normal
weight; BMI 25-30 kg/m2 as overweight, (which is equivalent to BMI-for-age >+1 and
<+2 z-scores) and BMI > 30 kg/m2 as obese (which is equivalent to BMI-for-age >+2 z-
scores)(31). Weight status was classified as a binary variable for the final models of this
study. As underweight/thinness (n=297; 3.6%) and obesity (n=346; 5,3%) frequencies
were low in this study, those classified as thinness/underweight were added to adequate
BMI-for-age/normal weight, and obese adolescents were incorporated into overweight
classification.
To estimate equivalent per capita monthly income the total income for the
household (self-reported) was equivalized according to the Organization for Economic
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Cooperation and Development (OECD) modified equivalence scale, which assigns weights
according to the number and age of household members(34-36). We used relative poverty to
describe the study sample. Relative poverty considers individuals’ position concerning the
overall living standards and lifestyles of their society(37). A household income 60% below
the mean or median is considered as relative poverty(38). We defined relative poverty as the
adolescents with equalized income below 60% of the Brazilian median (34-36).
Statistical analyses
We conducted an exploratory factor analysis with principal components estimation

and Varimax rotation to derive dietary breakfast patterns. We initially identified 18 food
groups of usual intakes. We considered eigenvalues over 1.5 and adequate communalities
equal to or above 0.10 to select the number of factors to be retained. After identifying the
number of factors (breakfast patterns), the Varimax rotation was performed to maximized
higher and minimized lower factor loadings, which simplifies interpretation. The cutoff
point over 0.25 (in the module) for the factor loadings after rotation was established for
each food group to compose the breakfast patterns. Then, factor scores were estimated by
regression analyses(39). For this study, food items were grouped considering their
nutritional value, the Brazilian population’s intake, and scientific literature on food
grouping to estimate dietary patterns(23,40,41). The food items that were mentioned by less
than 2.5% of the study sample were excluded from the analyses.
The National Cancer Institute method was applied to estimate usual food and
breakfast energy intakes to consider between and within person variability among food
records, episodically consumed foods, and asymmetric amount distribution(42).
The associations between breakfast skipping and breakfast patterns factor scores
with weight status were estimated by logistic regression modeling, crude, and adjusted for
potential confounders (sex, age, equivalent monthly per capita income, the region of the
country, and daily energy intake). Weight status was applied as a binary variable for these
analyses. Regression analyses considered the survey sample design’s complexity using
SAS OnDemand for Academics® (SAS Institute Inc., Cary, USA). This study was
conducted according to the Declaration of Helsinki and all procedures involving human
subjects were approved by the local ethics committee.
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Results
On average, adolescents were 14.5 years old, 35.3% were breakfast-skippers,

21.4% were overweight and 17.1% were living in relative poverty. The highest proportion
was from the Southeast area (39.4%). About 16.1% of adolescents in this study were
overweight, and 5.3% were obese. More girls than boys were thin. Adolescents who were
younger, relatively poor, and from the Southeast were more likely to be overweight or
obese. Adolescents from the Northeast were less likely to be overweight or obese, and
those from the North were less likely to be obese only (Table 1).
We identified three breakfast patterns of Brazilian adolescents, which explained

44.8% of data variability. We named the patterns following the food groups with higher
factor loadings. The Cereal, protein, fruit beverages and Northern/Northeastern pattern
pattern had positive loadings for cookies, meats, dairy products, preparations with corn,
eggs, fruit juices, fruit drinks or soy-based drinks, tubers, roots or potatoes, cereals, and
negative loadings cold cut meat, and savory snacks or crackers. The Protein-based diet
pattern had positive loadings for cold cut meat, milk, cheese, and negative for cookies, fruit
juices, fruit drinks or soy-based drinks, tubers, roots or potatoes, and cereals. The Mixed
pattern was characterized by the intake of cakes, coffee or tea, bread, fruit juices, fruit
drinks or soy-based drinks, chocolate or desserts, savory snacks, or crackers (Table 2).
Table 3 shows the logistic regression analyses for breakfast frequency, breakfast
patterns, and binary weight status, the response variable. There was no significant
association between skipping breakfast, Protein-based or Mixed breakfast patterns with
binary weight status. The Cereal, protein, fruit beverages and Northern/Northeastern
pattern was inversely associated with weight status (OR=0.67, p-value=0.028).
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Discussion
Brazilian adolescents who usually have breakfast encompass the three main
breakfast dietary patterns: the Cereal, protein, fruit beverages and Northern/Northeastern
pattern, named as such due to higher adherence to cookies, meats and dairy, accompanied
by beverages, but also to food groups that represent usual breakfast from North and
Northeast Brazilian regions, such as tubers, roots and potatoes, preparations with corn and
eggs, as observed in previous research using the same data of the present study(22); the
Protein-based pattern, characterized as such by the inclusion of milk, cheese and processed
meats; and a third breakfast pattern named Mixed, because bread and coffee, fruit juices
and cakes were the main breakfast consumed food items among Brazilian adolescents(22).
We also found that adolescents with overweight or obesity had lower adherence to the
Cereal, protein, fruit beverages and Northern/Northeastern pattern. Nevertheless, our study
showed no relationship between skipping breakfast and weight status.
In common, the three patterns of the study were composed of food items that
represent both a healthy and an unhealthy diet. On the one hand, the Cereal, protein, fruit
beverages and Northern/Northeastern pattern was characterized by a healthier diet due to
the higher adherence to traditional Brazilian food groups mostly consumed at breakfast
among adolescents from Northern (roots and tubers) and Northeastern regions (corn-based
dishes and eggs)(22). On the other hand, this pattern presented higher adherence to cookies,
and fruit and soy-based drinks. In common, both food groups are composed of homemade
and processed cookies and beverages as well as ultra-processed unhealthy cookies and
sugar-sweeetened beverages. The named Mixed pattern includes healthy food items
usually consumed by the Brazilian adolescents(43), such as coffee and bread, and also
unhealthier ones, as some sugar-sweetened beverages, chocolate, desserts, savory snacks,
and crackers. In the same sense, the protein-based includes both cold cut ultra-processed
food items and in natura or processed foods, such as cheese and milk.
Comparing our findings to overall dietary patterns for Brazilian adolescents, the
Study of Cardiovascular Risk in Adolescents (ERICA), a nationwide school-based survey
with adolescents aged 12 to 17 years, the authors also found three overall dietary patterns
for most Brazilian geographic regions. The labeled Mixed pattern was partially
characterized by most eaten food items usually consumed in Brazilian lunch and dinner,
which are rice, meat, and beans(43). Despite ERICA dietary patterns being evaluated on the
overall daily basis the authors labeled a Bread-and-coffee pattern which had similarities to
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the Mixed breakfast pattern from our study. Their Unhealthy pattern also has similarities
with some foods of our Mixed pattern which includes cakes and cookies, sugar-sweetened
beverages, and sweets/desserts. In the North region, the authors observed a fourth overall
dietary pattern characterized by typical regional foods, consisting of tubers, fruits, and
vegetables, which resembles the present study's Cereal, protein, fruit beverages and
Northern/Northeastern pattern(44). Other studies have shown that North and Northeast
Brazilian consume traditional local foods like fish with flours and starches, cassava, and
corn-based preparations, such as tapioca and corn couscous(45-47).
Another study with Brazilian adolescents that gathered data from the National
School-Based Health Survey (PeNSE)(48) with ninth-graders from private and public
schools identified three overall dietary patterns by cluster analysis. They labeled a Healthy
pattern characterized by a higher intake of cooked vegetables, fruits, milk, raw vegetables,
and beans and a lower intake of cookies, crackers, candy, soda, fried snacks, cold cuts, and
French fries.(48) Showing opposed frequencies, the authors found an overall dietary pattern
named Unhealthy, and a named Mixed pattern due to lower level of discrepancy between
consumption of the target foods. Through factor analysis of at-home and away-from-home
overall dietary patterns of adolescents aged 10-19 years from the NDS 2008-2009, Cunha
et al.(49) observed three overall dietary patterns for both places chosen for food
consumption: (1) Traditional, due to higher adherence to meat, rice and beans; (2) Bread-
and-Butter, similar to our Mixed breakfast pattern and; (3) the Western pattern,
unhealthier, with some food items commonly observed within our Protein-Based pattern.
Despite differences among studies, partially explained by different methods applied to
analyze food patterns and diverse study population, what the studies showed in common is
that Brazilian adolescents share both healthy and unhealthy dietary patterns, in particular,
at breakfast, which is of concern due to increasing consumption of ultra-processed
products and a reduction of traditional food items at this stage of life(44,50,51).
Our findings of overweight adolescents related with lower adherence to the Cereal,
protein, fruit beverages and Northern/Northeastern pattern may reflect the role of a higher
dietary fiber intake on excess body weight, as shown in two systematic reviews(52,53). In the
present study, the higher-fiber intake can be due to the consumption of cereals, tubers and
roots. Moreover, the lower glycemic index (GI) of the meat, dairy products and eggs as
sources of protein from this pattern could be associated to low daily energy intake and, thus,
a lower chance of being overweight (54,55). Examining 1,102 individuals aged 20 years and
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above from São Paulo, Brazil, a cross-sectional population-based survey revealed

associations between dietary patterns and metabolic cardiovascular disease risk factors(56). A
pattern with high positive loadings on rice and beans and low-to-moderate loadings on red
meats, eggs, whole milk, butter/margarine, and sugar was related to lower body weight and
waist circumference, and was mediated by serum leptin. These findings suggest a potential
protective role of dietary patterns based on higher dietary fiber intake and ower GI against
weight gain.
We did not identify another study in Brazil assessing the relationship between
breakfast patterns and overweight among adolescents, which make comparisons more
difficult. However, results in the same direction for Brazilian adults using NDS data were
found by Baltar et al.(23). The authors revealed a positive association between BMI and the
Northern Brazilian pattern, characterized by high consumption of meats, preparations with
corn, eggs, tubers/roots/potatoes, dairy products, savory snacks/crackers, fruit juices/fruit
drinks/soy-based drinks. The Southeastern Brazilian pattern was inversely associated with
BMI, characterized by cold cut meat, milk, cheese, coffee/tea, and bread,(23) which
resembles a combination of the Mixed and Protein-based patterns of our study. Healthier,
the Traditional Lebanese pattern (positive loadings for vegetables, legumes, bread, rice,
fruits, fish, and vegetable oils) was negatively associated with overweight (57). Longitudinal
studies are needed to further understand the role of breakfast composition on weight gain.
The cross-sectional survey in a nationally representative sample of 2,019 Swiss
adults derived dietary patterns using principal component analysis based on the intake of
22 breakfast-specific food groups(58). Of the three breakfast patterns, the Prudent breakfast,
characterized by fruit, unprocessed and unsweetened cereal flakes, nuts/seeds, yogurt, was
negatively associated with abdominal obesity, and the authors explained that the
association was partly due to a healthier diet in the rest of the day(58). No association was
observed between Traditional − white bread, butter, sweet spread – or Western breakfasts –
processed breakfast cereals and milk – and adiposity outcomes(58).
At the meal level, a study on 933 participants from the Health Survey of São Paulo,
Brazil, found greater adherence only to the Traditional lunch pattern associated with lower
BMI in insufficiently active individuals (24). This pattern was characterized of higher
contributions for rice, beans, cassava, flour, milk and sugar. Besides the Traditional
pattern, four other lunch patterns were derived from 22 food groups by factor analysis
(Western, Sweetened juice, Salad, and Meats) but none of them were significantly
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associated to the outcome(24). Other studies showed an inverse association between the
Traditional pattern (both overall and at the meal level) and weight outcomes such as waist
(41,59,60)
circumference and BMI . It is important to emphasize that the comparison between
studies is hampered by diverse findings and lack of studies at the meal level.
This study observed no association between skipping breakfast and weight status.
The scientific literature on the subject has mixed findings(61-68). While cross-sectional
studies consistently showed skipping breakfast related to overweight and obesity, contrary
to our findings, cohort and intervention studies have mixed observations(61-65). Thus,
systematic reviews and metanalyses recommend further investigation of the role of
breakfast frequency on body weight and adiposity outcomes(66-68).
One issue that deserves attention is the inconsistent definitions of breakfast and
breakfast-skipping(23,24,29,69). Prevalence levels vary greatly considering mixed definitions
of breakfast and skipping combined with different populations(23,24,29,69). While the
prevalence of skipping breakfast was 35.3% in our study, higher and lower values can be
found for Brazilian adolescents(23,24,29,69). Another study using the same data found 6.9% of
adolescents as skippers, but they only considered breakfast as the first meal of the day
eaten between 4 a.m. and 11 a.m.(22). In this study, breakfast definition considered the time
(5 to 10 a.m.) plus a minimum of 50 kcal of usual energy intake. A study evaluating high
school students from technical schools of São Paulo, Brazil, found a high breakfast-
skipping prevalence (51%)(70). The question "with whom the participants had breakfast"
implies the need for companionship at the meal and could explain skippers’ high
frequency. Baltar et al.(23) found similar skipping breakfast prevalence (33.1%) for
Brazilian adults. The authors applied the same breakfast definition as our study. Hassan et
al.(21) observed only 9.6% breakfast-skippers among sixth-graders from a study sample of
students from private and public schools of the metropolitan region of Rio de Janeiro,
Brazil. The authors observed that the prevalence increased to 26.1% when they changed
the definition to categorize irregular breakfast. The participants were asked how often they
had breakfast; those who responded less than five times a week were classified as having
irregular breakfast, and those who responded “never or almost never” were classified as
skippers. Consequently, comparisons between findings are hindered, and a consistent
method to evaluate breakfast is required.
Our study’s first limitation is the cross-sectional design that prevents causal
inference of the associations and, thus, our findings must be confirmed in prospective
studies. Second, residual confounding might have biased the associations between
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breakfast patterns and weight status despite the adjustment for potential confounders.
Third, the three identified breakfast patterns explained 44.8% of the total variance, which
explains most variance but is imperfect and reveals the complexity of breakfast patterns
among Brazilian adolescents. Other studies, however, showed some values around our
estimated variance. Baltar et al.(23) found that the three Brazilian adult’s breakfast patterns
explained 47.7% of the total variance. A Swiss study on adults found the three main
identified dietary patterns, which explained only 26% of the total variance(53). Fourth,
breakfast was not described by the study participants, and some may have had breakfast in
a broader period than the settled by the researchers and might be labeled as skippers. Fifth,
as we observed only one meal, we cannot affirm whether the associations were related to
breakfast eating alone or in combination with other eating occasions along the day;
however, the analysis was adjusted by daily energy intake. Sixth, because we used
secondary data there was no information on physical activity. Since weight gain depends
on the balance between the energy expenditure and dietary intake(71), adjustment for
physical activity should be taken into account in further studies.
The strengths of this study recall on data from a large, representative sample of the
Brazilian adolescent population. Furthermore, we derived a breakfast composition pattern
based on the usual food intake applying the NCI method. Adolescents’ daily food items
consumed may not be well represented because of data collection of only two non-
consecutive days food records. However, the NCI method's application enables regular food
consumption. Despite secondary data, our analyses were adjusted for most recognized
confounders. Finally, this is the first study examining adolescents’ breakfast patterns and
their association with weight status in Brazilian nationally-representative data.
Breakfast contribution to almost 1/5 (17.7%) of Brazilian adolescent’s daily energy

intake(22) and our study's national representativeness point out the need for health and food
policies to improve and value the breakfast eating at the age group. Dietary breakfast
patterns are still a blind spot despite studies focusing on the role of breakfast on several
health outcomes. Our study mainly adds to previous research given dietary patterns’
approach capacity to examine breakfast composition.
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Acknowledgments
We would like to thank everyone involved in the Household Budget Survey 2008-2009.
Financial support
This work was supported by The Brazilian National Council for Scientific and
Technological Development (CNPq, grant number 42446320180); and The
Coordination for the Improvement of Higher Education Personnel (B.K.H., grant number
88882306180201801).
Conflict of Interest
None.
Author contributions
B.K.H. and contributed to data analysis and manuscript writing. D.B.C. and R.O.S.
contributed to data analysis and manuscript revision.
V.T.B. contributed to study design and supervising, data analysis, manuscript conception
and final revision.
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https://doi.org/10.1017/S0007114521002403
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Accepted manuscript
TABLE 1. Main characteristics of Brazilian adolescents. National Dietary Survey 2008-2009. Total and according to weight
status.
Total Thinness Normal Overweight Obesity
3.56% 75.07% 16.05% 5.32%
(N = 1,192,871) (N = 25,151,725) (N = 5,377,664) (N = 1,781,411)
Breakfast frequency, % (N)
Eaters 64.72 68.61 64.21 66.80 63.05
(21,684,530) (818,531) (16,150,493) (3,592,364) (1,123,141)
Skippers 35.28 31.38 35.78 33.20 36.95
(11,819,141) (374,340) (9,001,232) (1,785,300) (658,270)
Gender, % (N)
Male 52.42 40.36 ‡ 52.33 55.88 51.24
(17,561,125) (481,427) (13,161,783) (3,005,116) (912,799)
Female 47.59 59.64 47.67 44.12 48.76
(15,942,546) (711,444) (11,989,942) (2,372,548) (868,612)
Age, mean (SD) 14.47 14.54 14.64 14.00 ‡ 13.41 ‡
(0.05) (0.22) (0.05) (0.13) (0.17)
Relative poverty, % (N)
> 60% of median 82.89 82.49 81.59 86.51† 90.63 †
(27,771,480) (984,037) (20,520,905) (4,651,974) (1,614,564)
https://doi.org/10.1017/S0007114521002403
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Accepted manuscript
< 60% of median 17.11 17.51 18.41 13.49 9.37

(5,732,191) (208,834) (4,630,820) (725,690) (166,847)
Brazilian Regions, % (N)
North 9.51 8.99 10.16 8.17 4.68*
(3,185,369) (107,177) (2,555,494) (439,267) (83,432)
Northeast 30.37 37.56 31.83 25.22* 20.53*
(10,175,204) (448,063) (8,005,348) (1,356,035) (365,758)
Midwest 7.33 8.38 7.52 6.93 5.10
(2,455,540) (99,977) (1,891,736) (372,905) (90,922)
Southeast 39.36 36.57 37.49 45.73* 48.40*
(13,187,961) (436,277) (9,430,424) (2,459,095) (8,621,660)
South 13.43 8.50 13.00 13.95 21.28
(4,499,596) (101,378) (3,268,722) (750,363) (379,133)
SD – standard deviation, P-values of Multinomial regression models: *p-value<0.05; †p-value<0.01; ‡p-value<0.001

Accepted manuscript
TABLE 2. Factor loadings of 18 food groups for three breakfast patterns among Brazilian
adolescents. National Dietary Survey 2008-2009.
Food Groups Factor 1 Factor 2 Factor 3 Communality

estimates
CPFBN† Protein Mixed
Meats 0.86* 0.10 0.03 0.75
Eggs 0.82* 0.07 0.01 0.68
Preparations with corn 0.81* 0.04 -0.17 0.69
Tuber, roots, or potatoes 0.75* -0.44 0.05 0.76
Dairy products‡ 0.70* -0.02 0.04 0.49
Cereals 0.67* -0.61* 0.00 0.82
Cookies 0.52* -0.33* -0.12 0.40
Fruit juices, fruit drinks, or soy-based drinks 0.43* -0.33* 0.43* 0.48
Cold cut meats -0.31* 0.74* 0.06 0.65
Cheese 0.13 0.73* -0.14 0.57
Milk -0.19 0.53* 0.11 0.33
Coffee or tea 0.13 0.10 0.64* 0.44
Savory snacks or crackers -0.40* 0.11 0.47* 0.39
Cakes -0.01 -0.09 0.45* 0.21
Chocolate or desserts¥ -0.09 0.07 0.44* 0.21
Bread 0.06 0.15 0.38* 0.17
Oil or butter 0.03 0.15 0.02 0.02
Fruits 0.03 0.06 -0.09 0.01
Eigenvalues 4.89 1.74 1.44
% of accumulated explained variance 27.16 36.80 44.82
* Pointed out as loads > |0.25|; ¥ Including chocolate drinks and candies; ‡ Excluding milk-based desserts
and cheese; † CPFBN: Cereal, protein, fruit beverages and Northern/Northeastern pattern
Accepted manuscript
TABLE 3. Odds ratios and Confidence Intervals of breakfast frequency and usual
breakfast dietary patterns in Brazilian adolescents for the outcome binary weight status.
National Dietary Survey 2008-2009. N = 4.991.
OR 95% CI
Model 1 – Breakfast frequency* 1.10 0.89, 1.36
Model 2 – Breakfast dietary patterns*
CPFBN† 0.67 0.47, 0.96
Protein-based 1.02 0.90, 1.17
Mixed 1.01 0.82, 1.25
OR – Odds Ratio; 95% CI – confidence intervals; *Logistic regression analysis was

adjusted for gender, age, equivalent monthly per capita income, region of the country
and daily energy intake; † CPFBN: Cereal, protein, fruit beverages and
Northern/Northeastern pattern

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*Corresponding author: Bruna Kulik Hassan. Address: Travessa Marquês de Paraná,

Running title: Breakfast patterns and weight status

Keywords: adolescent, body mass index, breakfast, dietary pattern, population-based.

Research on the role of breakfast skipping and breakfast composition on obesity

Study population and variables’ measurement

Brazilian representative study data on the cross-sectional National Dietary Survey

We conducted an exploratory factor analysis with principal components estimation

On average, adolescents were 14.5 years old, 35.3% were breakfast-skippers,

We identified three breakfast patterns of Brazilian adolescents, which explained

above from São Paulo, Brazil, a cross-sectional population-based survey revealed

Breakfast contribution to almost 1/5 (17.7%) of Brazilian adolescent’s daily energy

1. Meera S & Popkin B (2020) Obesity: Health and Economic Consequences of an

33. World Health Organization (2020) Global database on body mass

regions: analysis of the Study of Cardiovascular Risks in Adolescents (ERICA). Cad

58. Chatelan A, Castetbon K, Jerome Pasquier J et al. (2018) Association between

< 60% of median 17.11 17.51 18.41 13.49 9.37

SD – standard deviation, P-values of Multinomial regression models: *p-value<0.05; †p-value<0.01; ‡p-value<0.001

Food Groups Factor 1 Factor 2 Factor 3 Communality

Meats 0.86* 0.10 0.03 0.75

Eggs 0.82* 0.07 0.01 0.68

Preparations with corn 0.81* 0.04 -0.17 0.69

Tuber, roots, or potatoes 0.75* -0.44 0.05 0.76

Dairy products‡ 0.70* -0.02 0.04 0.49

Cereals 0.67* -0.61* 0.00 0.82

Cookies 0.52* -0.33* -0.12 0.40

Cold cut meats -0.31* 0.74* 0.06 0.65

Cheese 0.13 0.73* -0.14 0.57

Milk -0.19 0.53* 0.11 0.33

Coffee or tea 0.13 0.10 0.64* 0.44

Savory snacks or crackers -0.40* 0.11 0.47* 0.39

Cakes -0.01 -0.09 0.45* 0.21

Chocolate or desserts¥ -0.09 0.07 0.44* 0.21

Bread 0.06 0.15 0.38* 0.17

Oil or butter 0.03 0.15 0.02 0.02

Fruits 0.03 0.06 -0.09 0.01

Eigenvalues 4.89 1.74 1.44

% of accumulated explained variance 27.16 36.80 44.82

Model 1 – Breakfast frequency* 1.10 0.89, 1.36

Model 2 – Breakfast dietary patterns*

CPFBN† 0.67 0.47, 0.96

Protein-based 1.02 0.90, 1.17

Mixed 1.01 0.82, 1.25

OR – Odds Ratio; 95% CI – confidence intervals; *Logistic regression analysis was

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